US8401616B2 - Navigation system for cardiac therapies - Google Patents

Abstract

An image guided navigation system for navigating a region of a subject includes an imaging device, a tracking device, a controller, and a display. The imaging device generates images of the region of the subject. The tracking device tracks the location of the instrument in the subject. The controller superimposes an icon representative of the instrument onto the images generated from the imaging device based upon the tracked location of the instrument. The display displays the image with the superimposed instrument.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No. 12/730,714 filed on Mar. 24, 2010, now U.S. Pat. No. 8,046,052, issued Oct. 25, 2011, which is a continuation of U.S. patent application Ser. No. 10/619,216 filed on Jul. 14, 2003, now U.S. Pat. No. 7,697,972, issued Mar. 13, 2010, which is a continuation-in-part of U.S. patent application Ser. No. 10/299,969 filed on Nov. 19, 2002, now U.S. Pat. No. 7,599,730, issued Oct. 6, 2009, which are each hereby incorporated by reference.

FIELD OF THE INVENTION

The present invention relates generally to image guided surgery, and more specifically, to systems and methods for using one or more medical images to assist in navigating an instrument through internal body structures, in particular for navigating a catheter in a moving body structure, such as the heart, during a surgical procedure.

BACKGROUND OF THE INVENTION

Image guided medical and surgical procedures utilize patient images obtained prior to or during a medical procedure to guide a physician performing the procedure. Recent advances in imaging technology, especially in imaging technologies that produce highly-detailed, two, three, and four dimensional images, such as computed tomography (CT), magnetic resonance imaging (MRI), isocentric C-arm fluoroscopic imaging, positron emission tomography (PET), and ultrasound imaging (US) has increased the interest in image guided medical procedures.

At present, cardiac catheterization procedures are typically performed with the aid of fluoroscopic images. Two-dimensional fluoroscopic images taken intra-procedurally allow a physician to visualize the location of a catheter being advanced through cardiovascular structures. However, use of such fluoroscopic imaging throughout a procedure exposes both the patient and the operating room staff to radiation, as well as exposes the patient to contrast agents. Therefore, the number of fluoroscopic images taken during a procedure is preferably limited to reduce the radiation exposure to the patient and staff.

An image guided surgical navigation system that enables the physician to see the location of an instrument relative to a patient's anatomy, without the need to acquire real-time fluoroscopic images throughout the surgical procedure is generally disclosed in U.S. Pat. No. 6,470,207, entitled “Navigational Guidance Via Computer-Assisted Fluoroscopic Imaging,” issued Oct. 22, 2002, which is incorporated herein by reference in its entirety. In this system, representations of surgical instruments are overlaid on pre-acquired fluoroscopic images of a patient based on the position of the instruments determined by a tracking sensor.

Other types of procedures include the use of electro physiologic mapping catheters to map the heart based on measured electrical potentials. Such mapping catheters are useful in identifying an area of tissue that is either conducting normally or abnormally, however, some mapping catheters may not aid in actually guiding a medical device to a targeted tissue area for medical treatment.

Other procedures that could benefit from a navigation system include cardiac lead placement. Cardiac lead placement is important in achieving proper stimulation or accurate sensing at a desired cardiac location. Endocardial is one type of lead placement procedure that is an internal procedure where coronary vein leads are generally implanted with the use of a guide catheter and/or a guide wire or stylet to achieve proper placement of the lead. Epicardial is another type of procedure that is an external procedure for cardiac lead placement that may also benefit from this navigation system. A coronary vein lead may be placed using a multi-step procedure wherein a guide catheter is advanced into the coronary sinus ostium and a guide wire is advanced further through the coronary sinus and great cardiac vein to a desired cardiac vein branch. Because the tip of a guide wire is generally flexible and may be preshaped in a bend or curve, the tip of the guide wire can be steered into a desired venous branch. The guide wire tip is directed with a steerable guide catheter, and with the appropriate pressure, it is manipulated into the desired vein branch.

A cardiac lead may therefore be advanced to a desired implant location using a guide wire extending entirely through the lead and out its distal end. Cardiac leads generally need to be highly flexible in order to withstand flexing motion caused by the beating heart without fracturing. A stiff stylet or guide wire provides a flexible lead with the stiffness needed to advance it through a venous pathway. Leads placed with the use of a stylet or guide wire are sometimes referred to as “over-the-wire” leads. Once the lead is placed in a desired location, the guide wire and guide catheter may be removed. A guide wire placed implantable lead is disclosed in U.S. Pat. No. 6,192,280, entitled “Guide wire Placed Implantable Lead With Tip Seal,” issued Feb. 20, 2001. A coronary vein lead having a flexible tip and which may be adapted for receiving a stylet or guide wire is disclosed in U.S. Pat. No. 5,935,160, entitled “Left ventricular access lead for heart failure pacing”, issued Aug. 10, 1999, each of which are hereby incorporated by reference.

Also, pacing lead procedures currently performed today for use in heart failure treatment are not optimized. In this regard, the lead placement is not optimized due to the lack of having real-time anatomic information, navigation and localization information, hemo-dynamic data, and electrophysiological data. Thus, pacing leads are currently simply “stuffed” into the heart without any optimization being performed due to lack of information that can be used for this optimization.

Advancement of a guide catheter or an over-the-wire lead through a vessel pathway and through cardiac structures requires considerable skill and can be a time-consuming task. This type of procedure also exposes the patient to an undesirable amount of radiation exposure and contrast agent. Therefore, it is desirable to provide an image guided navigation system that allows the location of a guide catheter being advanced within the cardiovascular structures for lead placement to be followed in either two, three, or four dimensional space in real time. It is also desirable to provide an image guided navigation system that assists in navigating an instrument, such as a catheter, through a moving body structure or any type of soft tissue.

With regard to navigating an instrument through a moving body structure, difficulties arise in attempting to track such an instrument using known tracking technology as the instrument passes adjacent or through a moving body structure, since the virtual representation of the instrument may be offset from the corresponding anatomy when superimposed onto image data. Accordingly, it is also desirable to acquire image data and track the instrument in a synchronized manner with the pre-acquired image using gating or synchronization techniques, such as ECG gating or respiratory gating.

Other difficulties with cardiac procedures include annual check-ups to measure early indications for organ rejection in heart transplant patients. These indicators include white blood cells, chemical change, blood oxygen levels, etc. During the procedure, an endovascular biopsy catheter is inserted into the heart and multiple biopsies are performed in the septum wall of the heart. Again, during this procedure, radiation and contrast agent is utilized to visualize the biopsy catheter, thereby exposing both a patient and the doctor to potential excess radiation and contrast agents during the procedure. As such, it would also be desirable to provide an image guided navigation system that assists in performing this type of procedure in order to reduce radiation and contrast agent exposure.

Other types of surgical procedures also suffer from certain disadvantages. For example, with neurological diseases, these diseases are generally treated and accessed from the cranium down to the neurological site in order to reach tumors, ventricles, or treat different ailments, such as Parkinson's disease. This type of invasive procedure creates significant trauma, such as skull holes, dura opening, fiber destruction, and other cerebral structural damage or leakage. It is, therefore, also desirable to provide a minimally invasive approach to treat such ailments, which are accessible from either vascular or the cerebrospinal fluid tree.

Other types of vascular techniques includes use of a device referred to as an intravascular ultrasound (IVUS) technique. This type of technique is typically used to visualize tissue and/or blood vessels within the patient. This technique involves the use of a disposable catheter that includes an ultrasound transducer positioned within the catheter in order to provide two-dimensional ultrasound images as the catheter is passed through a vessel. However, this type of vascular technique has various drawbacks. For example, this type of disposable IVUS catheter is extremely expensive. Moreover, the ultrasound transducer embedded within the catheter provides only visualization on one side of the catheter, typically orthogonal to the catheter body, and therefore does not provide any forward views or other views about the catheter. Thus, here again, it is also desirable to provide an improved intravascular ultrasound approach, which substantially reduces the cost and increases the field of view of existing technologies. Still further, it is also desirable to register ultrasound image information with other or multiple image modalities, which are each registered to one another and viewed on a single or multiple displays.

SUMMARY OF THE INVENTION

A navigation system is provided including a catheter carrying single or multiple localization sensors, a sensor interface, a user interface, a controller, and a visual display. Aspects of the present invention allow for the location of a catheter advanced within an internal space within the human body, for example within the cardiovascular structures, to be identified in two, three or four dimensions in real time. Further aspects of the present invention allow for accurate mapping of a tissue or organ, such as the heart or other soft tissue, and/or precise identification of a desired location for delivering a medical lead or other medical device or therapy while reducing the exposure to fluoroscopy normally required during conventional catheterization procedures. These types of therapies include, but are not limited to, drug delivery therapy, cell delivery therapy, ablation, stenting, or sensing of various physiological parameters with the appropriate type of sensor. In cardiac applications, methods included in the present invention compensate for the effects of respiration and the beating heart that can normally complicate mapping or diagnostic data. Aspects of the present invention may be tailored to improve the outcomes of numerous cardiac therapies as well as non-cardiac therapies, such as neurological, oncological, or other medical therapies, including lung, liver, prostate and other soft tissue therapies, requiring the use of a catheter or other instrument at a precise location.

The steerable catheter provided by the present invention features at least one or more, location sensors located near the distal end of an elongated catheter body. The location sensors may be spaced axially from each other and may be electromagnetic detectors. An electromagnetic source is positioned externally to the patient for inducing a magnetic field, which causes voltage to be developed on the location sensors. The location sensors may be each electrically coupled to twisted pair conductors, which extend through the catheter body to the proximal catheter end. Twisted pair conductors provide electromagnetic shielding of the conductors, which prevents voltage induction along the conductors when exposed to the magnetic flux produced by the electromagnetic source. Alternatively, the sensors and the source may be reversed where the catheter emits a magnetic field that is sensed by external sensors.

By sensing and processing the voltage signals from each location sensor, the location of the catheter tip with respect to the external sources and the location of each sensor with respect to one another may be determined. The present invention allows a two, three, or four-dimensional reconstruction of several centimeters of the distal portion of the catheter body in real time. Visualization of the shape and position of a distal portion of the catheter makes the advancement of the catheter to a desired position more intuitive to the user. The system may also provide a curve fitting algorithm that is selectable based upon the type of catheter used, and based upon the flexibility of the catheter, based upon a path finding algorithm, and based upon image data. This enables estimated curved trajectories of the catheter to be displayed to assist the user.

In an alternative embodiment, the location sensors may be other types of sensors, such as conductive localization sensors, accelerometer localized sensors, fiberoptic localization sensors, or any other type of location sensor.

The catheter body is formed of a biocompatible polymer having stiffness properties that allow torsional or linear force applied to a handle at the proximal end to be transferred to the distal end in such a way that the catheter may be advanced in a desired direction. The catheter body includes multiple lumens for carrying conductors to sensors located at or near the distal end of the catheter and a guide wire extending from a proximal handle to the distal catheter tip. The guide wire aids in steering the catheter through a venous pathway, or other body lumens, and can be manipulated at its proximal end to cause bending or curving of the distal catheter tip.

In addition to the location sensors, the catheter may be equipped with one or more sensors for providing useful clinical data related to the catheter position or for identifying a target tissue site at which a medical device or medical therapy will be delivered. Additional sensors may include electrodes for sensing depolarization signals occurring in excitable tissue such as the heart, nerve or brain. In one embodiment, for use in cardiac applications, at least one electrode may be provided at or near the distal end of the catheter for sensing internal cardiac electrogram (EGM) signals. In other embodiments, an absolute pressure sensor may be provided on the catheter body near the distal end to monitor blood pressure. In still other embodiments, the catheter may be equipped with other sensors of physiological signals such as oxygen saturation or motion sensors.

The catheter body further provides a lumen through which a medical device or medical therapy may be delivered. For example, a medical lead for cardiac pacing or cardioversion or defibrillation may be introduced through a lumen of the catheter body. Alternatively, pharmaceutical agents, ablation catheters, cell therapies, genetic therapies, or other medical devices or therapies may be delivered through a lumen of the catheter body after it has been located at a targeted tissue site. The system may also provide a map identifying the delivery of the therapy, which can be annotated on 2D, 3D or 4D images or provided as a graphic representation of the cell or drug delivery. These distribution maps show how the drug, cell or other therapies are distributed on the heart or other soft tissue. The catheter may also be used to deliver energy for ablation, deliver hot/cold or thermal cutting apparatuses, deliver mechanical forces to provide therapy or deliver water jets to provide other means of cutting.

The location sensor conductors, as well as conductors coupled to other physiological sensors present, are coupled to a sensor interface for filtering, amplifying, and digitizing the sensed signals. The digitized signals are provided via a data bus to a control system, embodied as a computer. Programs executed by the control system process the sensor data for determining the location of the location sensors relative to a reference source. A determined location is superimposed on a two, three, or four-dimensional image that is displayed on a monitor. A user-interface, such as a keyboard, mouse or pointer, is provided for entering operational commands or parameters.

In one embodiment, a sensed EGM signal and/or an absolute pressure signal may be used in conjunction with location sensor data to establish and verify the location of the distal end of the catheter as it is advanced through the cardiovascular system. Characteristic EGM or pressure signals that are known to occur at different locations in the heart allow for location reference points to be recognized for further verification of the catheter location. The catheter may then be maneuvered through the cardiovascular structures with the location of the distal portion of the catheter superimposed on the heart model display as an icon or other soft tissue models.

In one embodiment, the catheter may also be provided with an automatic catheter-steering mechanism. Thermal shape-memory metal film may be incorporated in the distal portion of the catheter body. Selected heating of the metal film causes bending or curving of the catheter so that it may automatically be steered to a desired location.

In another embodiment, an image guided navigation system for guiding an instrument through a region of the patient includes an anatomic gating device, an imaging device, a tracking device, a controller and a display. The anatomic gating device senses a physiological event. The imaging device captures image data in response to the physiological event. The tracking device tracks the position of the instrument in the region of the patient. The controller is on communication with the anatomic gating device, the imaging device and the tracking device and registers the image data with the region of a patient in response to the physiological event. The controller also superimposes an icon representing the instrument onto the image data, based on the tracked position. The display displays the image data of the region of the patient with the superimposed icon of the instrument.

In another embodiment, an image guided navigation system for navigating to an optimized site in the patient using image data includes an instrument, a tracking device, at least one sensor, a controller and a display. The instrument is navigated to the optimized site. The tracking device is attached to the instrument and is used to track the position of the instrument in the patient. The sensor is attached to the instrument and senses a physiological parameter in the patient. The controller tracks the position of the instrument with the tracking device and receives the sensed physiological parameter from the sensor. The controller also estimates the optimized site and superimposes an icon representing the location of the optimized site and an icon representing the instrument, based on the sensed physiological parameter and the position of the instrument. The display displays the icon of the estimated optimized site and the icon representing the instrument in the patient.

In yet another embodiment, an image guided navigation system for navigating a region of a patient includes an imaging device, an instrument, a first tracking device, a controller and a display. The imaging device is positioned outside the patient and generates image data at the region of the patient. The instrument is navigated in the region of the patient. The first tracking device is attached to the instrument and is used to track the position of the instrument in the region of the patient. The controller generates virtual images along the navigated path of the instrument from the image data generated outside the patient. The display displays the virtual images.

In still another embodiment, a method for image guiding the instrument in a region of a patient includes identifying a physiological event, capturing image data during the physiological event, registering the captured image data to the patient during the physiological event, and displaying the location of the instrument on the image data by superimposing an icon of the instrument on the image data.

In still another embodiment, the method for image guiding an instrument to an optimized site includes navigating the instrument in the patient, detecting a location of the instrument, sensing a physiological parameter with the instrument, automatically determining an optimized site to navigate the instrument to and displaying an icon of the optimized site and an icon of the location of the catheter.

Further areas of applicability of the present invention will become apparent from the detailed description provided hereinafter. It should be understood that the detailed description and specific examples, while indicating the preferred embodiments of the invention, are intended for purposes of illustration only and are not intended to limit the scope of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

The present invention will become more fully understood from the detailed description and the accompanying drawings, wherein:

FIG. 1 is a diagram of a catheter navigation system according to the teachings of the present invention;

FIGS. 2aand2bare diagrams representing undistorted and distorted views from a fluoroscopic C-arm imaging device;

FIG. 3 is a logic block diagram illustrating a method for navigating a catheter during cardiac therapy;

FIGS. 4aand4bare side partial cross-sectional views of a navigable catheter employed in cardiac therapies according to the teachings of the present invention;

FIG. 5 is an axial cross-section view of the navigable catheter shown inFIGS. 4aand4b;

FIG. 6 is a logic block diagram illustrating a method for navigating and accessing a statistical atlas and employing the atlas for target suggestions according to the teachings of the present invention;

FIG. 7 is a figure of a display illustrating data available for a landmark accessible by a user of the system;

FIG. 8 is a figure of a display illustrating an adjustable icon or probe diameter;

FIG. 9 is a figure of the display illustrating a straight projection along a direction of a first sensor in the navigable catheter;

FIG. 10 is a figure of the display illustrating a splined projection or trajectory based on a shape of a curve of the navigable catheter;

FIG. 11 is a logic block diagram illustrating a method for navigating the coronary sinus region of the heart;

FIG. 12 is an image of a three-dimensional heart model used for cardiac therapy; and

FIG. 13 is a logic block diagram illustrating in further detail a method for navigating the coronary sinus region of the heart;

FIGS. 14aand14bare images of an ungated and a gated tracked catheter;

FIGS. 15a-15cillustrate a navigable catheter employed in cardiac therapies, according to the teachings of the present invention;

FIG. 16 is another embodiment of a catheter employed in cardiac therapies, according to the teachings of the present invention;

FIGS. 17aand17billustrate a navigable biopsy instrument, according to the teachings of the present invention;

FIGS. 18aand18billustrate a prior art intravascular ultrasound (IVUS) catheter;

FIG. 19 illustrates a virtual intravascular ultrasound catheter, according to the teachings of the present invention;

FIG. 20 illustrates a virtual intravascular ultrasound system, according to the teachings of the present invention;

FIG. 21 illustrates an exemplary catheter utilized according to the teachings of the present invention;

FIG. 22 illustrates an exemplary tracking insert utilized with the catheter ofFIG. 21; and

FIG. 23 illustrates the assembly of the insert and catheter ofFIGS. 21 and 22 according to the teachings of the present invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The following description of the preferred embodiment(s) is merely exemplary in nature and is in no way intended to limit the invention, its application, or uses. As indicated above, the present invention is directed at providing improved, non-line-of-site image-guided navigation of an instrument, such as a catheter, balloon catheter, implant, lead, stent, needle, guide wire, insert and/or capsule, that may be used for physiological monitoring, delivering a medical therapy, or guiding the delivery of a medical device in an internal body space, such as the heart or any other region of the body.

FIG. 1 is a diagram illustrating an overview of an image-guidedcatheter navigation system10 for use in non-line-of-site navigating of a catheter during cardiac therapy or any other soft tissue therapy. It should further be noted that thenavigation system10 may be used to navigate any other type of instrument or delivery system, including guide wires, needles, drug delivery systems, cell delivery systems, gene delivery systems and biopsy systems. Moreover, these instruments may be used for cardiac therapy or any other therapy in the body or be used to navigate or map any other regions of the body, such as moving body structures. However, each region of the body poses unique requirements to navigate, as disclosed herein. For example, thenavigation system10 addresses multiple cardiac, neurological, organ and other soft tissue therapies, including drug delivery, cell transplantation, gene delivery, electrophysiology ablations, transmyocardial vascularization (TMR), biopsy guidance, and virtual echography imaging.

Thenavigation system10 may include animaging device12 that is used to acquire pre-operative or real-time images of apatient14. Theimaging device12 is a fluoroscopic x-ray imaging device that may include a C-arm16 having anx-ray source18, anx-ray receiving section20, an optional calibration and trackingtarget22 andoptional radiation sensors24. The calibration and trackingtarget22 includes calibration markers26 (seeFIGS. 2a-2b), further discussed herein. A C-arm controller28 captures the x-ray images received at the receivingsection20 and stores the images for later use. The C-arm controller28 may also control the rotation of the C-arm16. For example, the C-arm16 may move in the direction ofarrow30 or rotates about the long axis of the patient, allowing anterior or lateral views of the patient14 to be imaged. Each of these movements involve rotation about amechanical axis32 of the C-arm16. In this example, the long axis of thepatient14 is substantially in line with themechanical axis32 of the C-arm16. This enables the C-arm16 to be rotated relative to thepatient14, allowing images of the patient14 to be taken from multiple directions or about multiple planes. An example of a fluoroscopic C-armx-ray imaging device12 is the “Series 9600 Mobile Digital Imaging System,” from OEC Medical Systems, Inc., of Salt Lake City, Utah. Other exemplary fluoroscopes include bi-plane fluoroscopic systems, ceiling fluoroscopic systems, cath-lab fluoroscopic systems, fixed C-arm fluoroscopic systems, isocentric C-arm fluoroscopic systems, 3D fluoroscopic systems, etc.

In operation, theimaging device12 generates x-rays from thex-ray source18 that propagate through thepatient14 and calibration and/or trackingtarget22, into thex-ray receiving section20. The receivingsection20 generates an image representing the intensities of the received x-rays. Typically, the receivingsection20 includes an image intensifier that first converts the x-rays to visible light and a charge coupled device (CCD) video camera that converts the visible light into digital images. Receivingsection20 may also be a digital device that converts x-rays directly to digital images, thus potentially avoiding distortion introduced by first converting to visible light. With this type of digital C-arm, which is generally a flat panel device, the optional calibration and/or trackingtarget22 and the calibration process discussed below may be eliminated. Also, the calibration process may be eliminated or not used at all for cardiac therapies. Alternatively, theimaging device12 may only take a single image with the calibration and trackingtarget22 in place. Thereafter, the calibration and trackingtarget22 may be removed from the line-of-sight of theimaging device12.

Two dimensional fluoroscopic images taken by theimaging device12 are captured and stored in the C-arm controller28. Multiple two-dimensional images taken by theimaging device12 may also be captured and assembled to provide a larger view or image of a whole region of a patient, as opposed to being directed to only a portion of a region of the patient. For example, multiple image data of a patient's leg may be appended together to provide a full view or complete set of image data of the leg that can be later used to follow contrast agent, such as Bolus tracking. These images are then forwarded from the C-arm controller28 to a controller orwork station34 having adisplay36 and auser interface38. Thework station34 provides facilities for displaying on thedisplay36, saving, digitally manipulating, or printing a hard copy of the received images. Theuser interface38, which may be a keyboard, mouse, touch pen, touch screen or other suitable device, allows a physician or user to provide inputs to control theimaging device12, via the C-arm controller28, or adjust the display settings of thedisplay36. Thework station34 may also direct the C-arm controller28 to adjust therotational axis32 of the C-arm16 to obtain various two-dimensional images along different planes in order to generate representative two-dimensional and three-dimensional images. When thex-ray source18 generates the x-rays that propagate to thex-ray receiving section20, theradiation sensors24 sense the presence of radiation, which is forwarded to the C-arm controller28, to identify whether or not theimaging device12 is actively imaging. This information is also transmitted to acoil array controller48, further discussed herein. Alternatively, a person or physician may manually indicate when theimaging device12 is actively imaging or this function can be built into thex-ray source18,x-ray receiving section20, or thecontrol computer28.

Fluoroscopic C-arm imaging devices12 that do not include adigital receiving section20 generally require the optional calibration and/or trackingtarget22. This is because the raw images generated by the receivingsection20 tend to suffer from undesirable distortion caused by a number of factors, including inherent image distortion in the image intensifier and external electromagnetic fields. An empty undistorted or ideal image and an empty distorted image are shown inFIGS. 2aand2b, respectively. The checkerboard shape, shown inFIG. 2a, represents theideal image40 of the checkerboard arrangedcalibration markers26. The image taken by the receivingsection20, however, can suffer from distortion, as illustrated by the distortedcalibration marker image42, shown inFIG. 2b.

Intrinsic calibration, which is the process of correcting image distortion in a received image and establishing the projective transformation for that image, involves placing thecalibration markers26 in the path of the x-ray, where thecalibration markers26 are opaque or semi-opaque to the x-rays. Thecalibration markers26 are rigidly arranged in pre-determined patterns in one or more planes in the path of the x-rays and are visible in the recorded images. Because the true relative position of thecalibration markers26 in the recorded images are known, the C-arm controller28 or the work station orcomputer34 is able to calculate an amount of distortion at each pixel in the image (where a pixel is a single point in the image). Accordingly, the computer orwork station34 can digitally compensate for the distortion in the image and generate a distortion-free or at least a distortion improved image40 (seeFIG. 2a). A more detailed explanation of exemplary methods for performing intrinsic calibration are described in the references: B. Schuele, et al., “Correction of Image Intensifier Distortion for Three-Dimensional Reconstruction,” presented at SPIE Medical Imaging, San Diego, Calif., 1995; G. Champleboux, et al., “Accurate Calibration of Cameras and Range Imaging Sensors: the NPBS Method,” Proceedings of the IEEE International Conference on Robotics and Automation, Nice, France, May, 1992; and U.S. Pat. No. 6,118,845, entitled “System And Methods For The Reduction And Elimination Of Image Artifacts In The Calibration Of X-Ray Imagers,” issued Sep. 12, 2000, the contents of which are each hereby incorporated by reference.

While thefluoroscopic imaging device12 is shown inFIG. 1, any other alternative 2D, 3D or 4D imaging modality may also be used. For example, any 2D, 3D or 4D imaging device, such as isocentric fluoroscopy, bi-plane fluoroscopy, ultrasound, computed tomography (CT), multi-slice computed tomography (MSCT), magnetic resonance imaging (MRI), high frequency ultrasound (HIFU), positron emission tomography (PET), optical coherence tomography (OCT), intra-vascular ultrasound (IVUS), ultrasound, intra-operative CT or MRI may also be used to acquire 2D, 3D or 4D pre-operative or real-time images or image data of thepatient14. The images may also be obtained and displayed in two, three or four dimensions. In more advanced forms, four-dimensional surface rendering of the heart or other regions of the body may also be achieved by incorporating heart data or other soft tissue data from an atlas map or from pre-operative image data captured by MRI, CT, or echocardiography modalities. A more detailed discussion on optical coherence tomography (OCT), is set forth in U.S. Pat. No. 5,740,808, issued Apr. 21, 1998, entitled “Systems And Methods For Guiding Diagnostic Or Therapeutic Devices In Interior Tissue Regions” which is hereby incorporated by reference.

Image datasets from hybrid modalities, such as positron emission tomography (PET) combined with CT, or single photon emission computer tomography (SPECT) combined with CT, could also provide functional image data superimposed onto anatomical data to be used to confidently reach target sights within the heart or other areas of interest. It should further be noted that thefluoroscopic imaging device12, as shown inFIG. 1, provides a virtual bi-plane image using a single-head C-arm fluoroscope12 by simply rotating the C-arm16 about at least two planes, which could be orthogonal planes to generate two-dimensional images that can be converted to three-dimensional volumetric images. By acquiring images in more than one plane, an icon representing the location of a catheter or other instrument, introduced and advanced in thepatient14, may be superimposed in more than one view ondisplay36 allowing simulated bi-plane or even multi-plane views, including two and three-dimensional views.

These types of imaging modalities may provide certain distinct benefits and disadvantages for their use. For example, magnetic resonance imaging (MRI) is generally performed pre-operatively using a non-ionizing field. This type of imaging provides very good tissue visualization in three-dimensional form and also provides anatomy and functional information from the imaging. MRI imaging data is generally registered and compensated for motion correction using dynamic reference frames that are discussed herein.

Positron emission tomography (PET) imaging is generally a pre-operative imaging procedure that exposes the patient to some level of radiation to provide a 3D image. PET imaging provides functional information and also generally requires registration and motion correction using dynamic reference frames.

Computed tomography (CT) imaging is also generally a pre-operative technique that exposes the patient to a limited level of radiation. CT imaging, however, is a very fast imaging procedure. A multi-slice CT system provides 3D images having good resolution and anatomy information. Again, CT imaging is generally registered and needs to account for motion correction, via dynamic reference frames.

Fluoroscopy imaging is generally an intra-operative imaging procedure that exposes the patient to certain amounts of radiation to provide either two-dimensional or rotational three-dimensional images. Fluoroscopic images generally provide good resolution and anatomy information. Fluoroscopic images can be either manually or automatically registered and also need to account for motion correction using dynamic reference frames.

Ultrasound imaging is also generally intra-operative procedure using a non-ionizing field to provide either 2D, 3D, or 4D imaging, including anatomy and blood flow information. Ultrasound imaging provides automatic registration and does not need to account for any motion correction.

Thenavigation system10 further includes an electromagnetic navigation or trackingsystem44 that includes atransmitter coil array46, thecoil array controller48, anavigation probe interface50, anelectromagnetic catheter52 or any other type of instrument and adynamic reference frame54. It should further be noted that theentire tracking system44 or parts of thetracking system44 may be incorporated into theimaging device12, including thework station34 andradiation sensors24. Incorporating thetracking system44 will provide an integrated imaging and tracking system. Any combination of these components may also be incorporated into theimaging system12, which again can include a fluoroscopic C-arm imaging device or any other appropriate imaging device.

Thetransmitter coil array46 is shown attached to the receivingsection20 of the C-arm16. However, it should be noted that thetransmitter coil array46 may also be positioned at any other location as well. For example, thetransmitter coil array46 may be positioned at thex-ray source18, within or atop the OR table56 positioned below thepatient14, on siderails associated with the table56, or positioned on the patient14 in proximity to the region being navigated, such as on the patient's chest. Thetransmitter coil array46 includes a plurality of coils that are each operable to generate distinct electromagnetic fields into the navigation region of thepatient14, which is sometimes referred to as patient space. Representative electromagnetic systems are set forth in U.S. Pat. No. 5,913,820, entitled “Position Location System,” issued Jun. 22, 1999 and U.S. Pat. No. 5,592,939, entitled “Method and System for Navigating a Catheter Probe,” issued Jan. 14, 1997, each of which are hereby incorporated by reference.

Thetransmitter coil array46 is controlled or driven by thecoil array controller48. Thecoil array controller48 drives each coil in thetransmitter coil array46 in a time division multiplex or a frequency division multiplex manner. In this regard, each coil may be driven separately at a distinct time or all of the coils may be driven simultaneously with each being driven by a different frequency. Upon driving the coils in thetransmitter coil array46 with thecoil array controller48, electromagnetic fields are generated within thepatient14 in the area where the medical procedure is being performed, which is again sometimes referred to as patient space. The electromagnetic fields generated in the patient space induces currents insensors58 positioned in thecatheter52, further discussed herein. These induced signals from thecatheter52 are delivered to thenavigation probe interface50 and subsequently forwarded to thecoil array controller48. Thenavigation probe interface50 provides all the necessary electrical isolation for thenavigation system10. Thenavigation probe interface50 also includes amplifiers, filters and buffers required to directly interface with thesensors58 incatheter52. Alternatively, thecatheter52 may employ a wireless communications channel as opposed to being coupled directly to thenavigation probe interface50.

Thecatheter52, as will be described in detail below, is equipped with at least one, and generally multiple,localization sensors58. Thecatheter54 is also generally a steerable catheter that includes a handle at a proximal end and themultiple location sensors58 fixed to the catheter body and spaced axially from one another along the distal segment of thecatheter52. Thecatheter52, as shown inFIG. 1 includes fourlocalization sensors58. Thelocalization sensors58 are generally formed as electromagnetic receiver coils, such that the electromagnetic field generated by thetransmitter coil array46 induces current in the electromagnetic receiver coils orsensors58. Thecatheter52 may also be equipped with one or more sensors, which are operable to sense various physiological signals. For example, thecatheter52 may be provided with electrodes for sensing myopotentials or action potentials. An absolute pressure sensor may also be included, as well as other electrode sensors. Thecatheter52 may also be provided with an open lumen, further discussed herein, to allow the delivery of a medical device or pharmaceutical/cell/gene agents. For example, thecatheter52 may be used as a guide catheter for deploying a medical lead, such as a cardiac lead for use in cardiac pacing and/or defibrillation or tissue ablation. The open lumen may alternatively be used to locally deliver pharmaceutical agents, cell, or genetic therapies.

In an alternate embodiment, the electromagnetic sources or generators may be located within thecatheter52 and one or more receiver coils may be provided externally to the patient14 forming a receiver coil array similar to thetransmitter coil array46. In this regard, the sensor coils58 would generate electromagnetic fields, which would be received by the receiving coils in the receiving coil array similar to thetransmitter coil array46. Other types of localization sensors or systems may also be used, which may include an emitter, which emits energy, such as light, sound, or electromagnetic radiation, and a receiver that detects the energy at a position away from the emitter. This change in energy, from the emitter to the receiver, is used to determine the location of the receiver relative to the emitter. Other types of tracking systems include optical, acoustic, electrical field, RF and accelerometers. Accelerometers enable both dynamic sensing due to motion and static sensing due to gravity. An additional representative alternative localization and tracking system is set forth in U.S. Pat. No. 5,983,126, entitled “Catheter Location System and Method,” issued Nov. 9, 1999, which is hereby incorporated by reference. Alternatively, the localization system may be a hybrid system that includes components from various systems.

Thedynamic reference frame54 of theelectromagnetic tracking system44 is also coupled to thenavigation probe interface50 to forward the information to thecoil array controller48. Thedynamic reference frame54 is a small magnetic field detector that is designed to be fixed to the patient14 adjacent to the region being navigated so that any movement of thepatient14 is detected as relative motion between thetransmitter coil array46 and thedynamic reference frame54. This relative motion is forwarded to thecoil array controller48, which updates registration correlation and maintains accurate navigation, further discussed herein. Thedynamic reference frame54 can be configured as a pair of orthogonally oriented coils, each having the same center or may be configured in any other non-coaxial coil configuration. Thedynamic reference frame54 may be affixed externally to thepatient14, adjacent to the region of navigation, such as on the patient's chest, as shown inFIG. 1 or on the patient's back. Thedynamic reference frame54 can be affixed to the patient's skin, by way of a stick-on adhesive patch. Thedynamic reference frame54 may also be removably attachable tofiducial markers60 also positioned on the patient's body and further discussed herein.

Alternatively, thedynamic reference frame54 may be internally attached, for example, to the wall of the patient's heart or other soft tissue using a temporary lead that is attached directly to the heart. This provides increased accuracy since this lead will track the regional motion of the heart. Gating, as further discussed herein, will also increase the navigational accuracy of thesystem10. An exemplarydynamic reference frame54 andfiducial marker60, is set forth in U.S. Pat. No. 6,381,485, entitled “Registration of Human Anatomy Integrated for Electromagnetic Localization,” issued Apr. 30, 2002, which is hereby incorporated by reference. It should further be noted that multipledynamic reference frames54 may also be employed. For example, an externaldynamic reference frame54 may be attached to the chest of thepatient14, as well as to the back of thepatient14. Since certain regions of the body may move more than others due to motions of the heart or the respiratory system, eachdynamic reference frame54 may be appropriately weighted to increase accuracy even further. In this regard, thedynamic reference frame54 attached to the back may be weighted higher than thedynamic reference frame54 attached to the chest, since thedynamic reference frame54 attached to the back is relatively static in motion.

The catheter andnavigation system10 further includes a gating device or an ECG orelectrocardiogram62, which is attached to thepatient14, viaskin electrodes64, and in communication with thecoil array controller48. Respiration and cardiac motion can cause movement of cardiac structures relative to thecatheter54, even when thecatheter54 has not been moved. Therefore, localization data may be acquired on a time-gated basis triggered by a physiological signal. For example, the ECG or EGM signal may be acquired from theskin electrodes64 or from a sensing electrode included on thecatheter54 or from a separate reference probe. A characteristic of this signal, such as an R-wave peak or P-wave peak associated with ventricular or atrial depolarization, respectively, may be used as a triggering event for thecoil array controller48 to drive the coils in thetransmitter coil array46. This triggering event may also be used to gate or trigger image acquisition during the imaging phase with theimaging device12. By time-gating or event gating at a point in a cycle the image data and/or the navigation data, the icon of the location of thecatheter52 relative to the heart at the same point in the cardiac cycle may be displayed on thedisplay36, further discussed herein.

Additionally or alternatively, a sensor regarding respiration may be used to trigger data collection at the same point in the respiration cycle. Additional external sensors can also be coupled to thenavigation system10. These could include a capnographic sensor that monitors exhaled CO₂concentration. From this, the end expiration point can be easily determined. The respiration, both ventriculated and spontaneous causes an undesirable elevation or reduction (respectively) in the baseline pressure signal. By measuring systolic and diastolic pressures at the end expiration point, the coupling of respiration noise is minimized. As an alternative to the CO₂sensor, an airway pressure sensor can be used to determine end expiration.

Briefly, thenavigation system10 operates as follows. Thenavigation system10 creates a translation map between all points in the radiological image generated from theimaging device12 and the corresponding points in the patient's anatomy in patient space. After this map is established, whenever a tracked instrument, such as thecatheter52 or pointing device is used, thework station34 in combination with thecoil array controller48 and the C-arm controller28 uses the translation map to identify the corresponding point on the pre-acquired image, which is displayed ondisplay36. This identification is known as navigation or localization. An icon representing the localized point or instruments are shown on thedisplay36 within several two-dimensional image planes, as well as on three and four dimensional images and models.

To enable navigation, thenavigation system10 must be able to detect both the position of the patient's anatomy and the position of thecatheter52 or other surgical instrument. Knowing the location of these two items allows thenavigation system10 to compute and display the position of thecatheter52 in relation to thepatient14. Thetracking system44 is employed to track thecatheter52 and the anatomy simultaneously.

Thetracking system44 essentially works by positioning thetransmitter coil array46 adjacent to the patient space to generate a low-energy magnetic field generally referred to as a navigation field. Because every point in the navigation field or patient space is associated with a unique field strength, theelectromagnetic tracking system44 can determine the position of thecatheter52 by measuring the field strength at thesensor58 location. Thedynamic reference frame54 is fixed to the patient14 to identify the location of the patient in the navigation field. Theelectromagnetic tracking system44 continuously recomputes the relative position of thedynamic reference frame54 and thecatheter52 during localization and relates this spatial information to patient registration data to enable image guidance of thecatheter52 within thepatient14.

Patient registration is the process of determining how to correlate the position of the instrument orcatheter52 on the patient14 to the position on the diagnostic or pre-acquired images. To register thepatient14, the physician or user may use point registration by selecting and storing particular points from the pre-acquired images and then touching the corresponding points on the patient's anatomy with apointer probe66. Thenavigation system10 analyzes the relationship between the two sets of points that are selected and computes a match, which correlates every point in the image data with its corresponding point on the patient's anatomy or the patient space. The points that are selected to perform registration are the fiducial arrays orlandmarks60. Again, the landmarks orfiducial points60 are identifiable on the images and identifiable and accessible on thepatient14. Thelandmarks60 can beartificial landmarks60 that are positioned on the patient14 or anatomical landmarks that can be easily identified in the image data. Thesystem10 may also perform registration using anatomic surface information or path information, further discussed herein. Thesystem10 may also perform 2D to 3D registration by utilizing the acquired 2D images to register 3D volume images by use of contour algorithms, point algorithms or density comparison algorithms, as is known in the art. An exemplary 2D to 3D registration procedure, as set forth in U.S. Ser. No. 60/465,615, entitled “Method and Apparatus for Performing 2D to 3D Registration” filed on Apr. 25, 2003, which is hereby incorporated by reference. The registration process may also be synched to an anatomical function, for example, by the use of theECG device62, further discussed herein.

In order to maintain registration accuracy, thenavigation system10 continuously tracks the position of the patient14 during registration and navigation. This is because thepatient14,dynamic reference frame54, andtransmitter coil array46 may all move during the procedure, even when this movement is not desired. Therefore, if thenavigation system10 did not track the position of the patient14 or area of the anatomy, any patient movement after image acquisition would result in inaccurate navigation within that image. Thedynamic reference frame54 allows theelectromagnetic tracking device44 to register and track the anatomy. Because thedynamic reference frame54 is rigidly fixed to thepatient14, any movement of the anatomy or thetransmitter coil array46 is detected as the relative motion between thetransmitter coil array46 and thedynamic reference frame54. This relative motion is communicated to thecoil array controller48, via thenavigation probe interface50, which updates the registration correlation to thereby maintain accurate navigation.

Turning now toFIG. 3, a logic flow diagram illustrating an exemplary operation of thenavigation system10 is set forth in further detail. First, should theimaging device12 or the fluoroscopic C-arm imager12 not include adigital receiving section20, theimaging device12 is first calibrated using thecalibration process68. Thecalibration process68 begins atblock70 by generating an x-ray by thex-ray source18, which is received by thex-ray receiving section20. Thex-ray image70 is then captured or imported atimport block72 from the C-arm controller28 to thework station34. Thework station34 performs intrinsic calibration atcalibration block74, as discussed above, utilizing thecalibration markers26, shown inFIGS. 2aand2b. This results in an empty image being calibrated atblock76. This calibrated empty image is utilized for subsequent calibration and registration, further discussed herein.

Once theimaging device12 has been calibrated, thepatient14 is positioned within the C-arm16 between thex-ray source18 and thex-ray receiving section20. The navigation process begins atdecision block78 where it is determined whether or not an x-ray image of thepatient14 has been taken. If the x-ray image has not been taken, the process proceeds to block80 where the x-ray image is generated at thex-ray source18 and received at thex-ray receiving section20. When thex-ray source18 is generating x-rays, theradiation sensors24 identified inblock82 activate to identify that thex-ray image80 is being taken. This enables thetracking system44 to identify where the C-arm16 is located relative to the patient14 when the image data is being captured.

The process then proceeds todecision block84 where it is determined if the x-ray image acquisition will be gated to physiological activity of thepatient14. If so, theimage device12 will capture the x-ray image at this desired gating time. For example, the physiological change may be the beating heart, which is identified by ECG gating atblock86. The ECG gating enables the x-ray image acquisition to take place at the end of diastole atblock88 or at any other cycle. Diastole is the period of time between contractions of the atria or the ventricles during which blood enters the relaxed chambers from systemic circulation and the lungs. Diastole is often measured as the blood pressure at the instant of maximum cardiac relaxation. ECG gating of myocardial injections also enables optimal injection volumes and injection rates to achieve maximum cell retention. The optimal injection time period may go over one heart cycle. During the injection, relative motion of the catheter tip to the endocardial surface needs to be minimized. Conductivity electrodes at the catheter tip may be used to maintain this minimized motion. Also, gating the delivery of volumes can be used to increase or decrease the volume delivered over time (i.e., ramp-up or ramp-down during cycle). Again, the image may be gated to any physiological change like the heartbeat, respiratory functions, etc. The image acquired atblock88 is then imported to thework station34 atblock90. If it is not desired to physiologically gate the image acquisition cycle, the process will proceed from thex-ray image block80 directly to theimage import block90.

Once the image is received and stored in thework station34, the process proceeds to calibration and registration atblock92. First, atdecision block94, it is determined whether theimaging device12 has been calibrated, if so, the empty image calibration information fromblock76 is provided for calibration registration atblock92. The empty image calibration information fromblock76 is used to correct image distortion by establishing projective transformations using known calibration marker locations (seeFIGS. 2aand2b).Calibration registration92 also requires tracking of thedynamic reference frame54. In this regard, it is first determined atdecision block96 whether or not the dynamic reference frame is visible, viablock98. With thedynamic reference frame54 visible or in the navigation field and the calibration information provided, thework station34 and thecoil array controller48, via thenavigation probe interface50 performs thecalibration registration92 functions. In addition to monitoring thedynamic reference frame54, the fiducial array orlandmarks60 may also be used for image registration.

Once thenavigation system10 has been calibrated and registered, navigation of an instrument, such as thecatheter52 is performed. In this regard, once it is determined atdecision block100 that thecatheter54 is visible or in the navigation field atblock102, an icon representing thecatheter52 is superimposed over the pre-acquired images atblock104. Should it be determined to match the superimposed image of thecatheter52 with the motion of the heart atdecision block106, ECG gating atblock108 is performed. Thecatheter52 may then be navigated, vianavigation block110 throughout the anatomical area of interest in thepatient14.

Turning toFIGS. 4-5, anexemplary catheter52 is shown in further detail. The exemplary catheter, as shown inFIG. 4a, includes an externalflexible body112 and aproximal handle114. Positioned within thecatheter52 are the foursensing coils58 disposed distally in thecatheter52. The localization or sensing coils58 are multi-layer and multi-turn coils, which are coupled to four sets oftwisted pair conductors116. Thecatheter52 further includes apull wire118, which is used to control and guide thedistal tip120 of thecatheter52. Extending through thecatheter52 is acentral lumen122 that can be used to deliver and transport cells or drug therapy and leads for cardiac pacemakers. Thecentral lumen122, shown inFIG. 4bretains ahypodermic needle124 that can be used as the delivery instrument. Thecatheter52 further includeselectrode conductors126 and anelectrode tip ring128 used to sense various electrical signals from the heart. Other sensors that can be attached to thecatheter52 include multiple electrode sensors, absolute pressure sensors, accelerometers and oxygen saturation sensors. Formapping catheters52, micro-motion arrays, further discussed herein, may also be embedded to electronically control curvature of thecatheter52 to provide a semi-automated mapping procedure.

Turning toFIG. 5, the axial cross-section of thecatheter52 is shown in further detail. Thecatheter52 is again formed from theouter cover112 that is formed from an extruded polymer having sixdirectional splines130. Aninternal extrusion132 defines six chambers orlumens134 between theinternal extrusion132 andexternal extrusion112. Within four of thechambers134 are the fourtwisted pair conductors116, which are coupled to each of the coils orsensors58. Located in anotherchamber132 are theelectrode conductors126. Thepull wire118 is located in the remainingchamber132. By adjusting thepull wire118 along with the torque transferring splines130, thedirectional catheter52 can be positioned and steered as desired. Also, located within the center of thecatheter52 is thelumen122 housing thehypodermic needle124 having acentral port136 for passing cells, catheter leads and other items. Further details of thecatheter52, as well as other embodiments of thecatheter52 are set forth in U.S. Ser. No. 10/299,484, entitled “Multi-Lumen Body for Medical Catheter and Leads,” naming as inventors Kenneth Gardeski, Michael Leners and Jesus Casas-Bejar, filed Nov. 19, 2002, which is hereby incorporated by reference. Again, thecatheter52 may include alumen122 open on both ends, which allows it to be used to deliver several cardiac therapies (e.g., to implant pacing leads, deliver drugs, to transplant cells into the myocardium, or to perform complex electrophysiological procedures, including ablation).

Thenavigation system10 enhances minimally invasive cardiac therapies by making the procedure more intuitive. Thecatheter52 can be used to implant pacing leads, perform cell transplantation, deliver drugs or perform ablations. Thecatheter52 having navigation guidance, viasensors58 provides enhanced outcomes by making lead placement more successful in difficult anatomies, by insuring cells are transplanted in the most viable myocardium within the infarct, etc. Moreover, use of theelectrocardiogram device62 enables further gating of the drug deliver and cell delivery at the most optimum times for providing additional capabilities to thenavigation system10. Thenavigation system10 can also be applied to non-cardiac therapies, such as neuro-vascular catheters, or oncology drug delivery applications, based on combined PET/CT (functional and anatomical) pre-operative data or pre-operative data from any other bio-imaging system for tumor identification and location. Thenavigation system10 can also map on thedisplay36 the delivery of cell or drug therapy or other therapies that are annotated on 2D, 3D or 4D images or graphic displays. Thenavigation system10 may also generate distribution maps on how the cell or drug delivery or other therapies are disbursed through the region of interest, such as the heart. These iso-contours or iso-dose contours display how therapy is disbursed through the tissue. For example, a bullseye type graphic may be displayed on the three-dimensional heart model with different concentric rings having different colors identifying the amount of drug therapy delivered to the noted regions.

Thenavigation system10 can also be used and employed in several types of medical procedures and has several improvements and advantages over existing systems. Thenavigation system10 provides application and methods for electromagnetic non-line-of-site navigation for catheter delivery of pacing leads. Thenavigation system10 includes heuristics that are integrated into the software of thework station34 to provide an algorithm for locating the coronary sinus, further discussed herein. Thenavigation system10 provides for gating or timing of injections for cell transplantation in the infarcted myocardium as a substitute for anchoring. The cell delivery imaging modality is generally utilized as real-time MR. Real time MR allows catheter navigation while visualizing the infarcted region of the heart. Use of pre-operative profusion MR images may also be used to clearly identify the infarct region, along with the quality of the infarct. Thenavigation system10 also includes integrated programming functions in thework station34 that are used to help identify optimum pacing sites, further discussed herein. Also, thenavigation system10 provides a simulated bi-plane or multi-plane fluoroscopy for cardiac applications with one-head systems and also catheter registration to the images, whether fluoroscopic or volume-rendered using MR, CT, and moving surfaces.

Turning now toFIG. 6, an exemplarylead implant procedure138 is shown in detail. While this procedure is described regarding implanting a lead for a pacemaker, it should again be noted that this process can be applied to any type of cardiac therapy as discussed herein, such as angioplasty, stenting, and ablation. The lead placement procedure disclosed herein is designed to reduce the procedure time and reduce the procedure costs and enable a physician to implant a lead quicker, safer and in a more precise optimized location.Delivery catheters52 are, therefore, very important with cardiac resynchronization therapy. Thecatheter52 and fluoroscopic images are used to find and cannulate the coronary sinus. Once cannulated, a lead is delivered through thecatheter52 and into the cardiac veins.

Various types ofcatheters52 may be utilized to deliver a lead to the desired cardiac location, via thecentral port136 in thehypodermic needle124. Thecatheter52 may include thecatheter electrode128, which could be used to monitor the intra-cardiac electrical signals. Since each region in the heart has characteristic differences, these differences can be used to distinguish which region thecatheter tip120 is placed within the heart. In addition to monitoring intra-cardiac electrical signals, electrical impedance (high and low frequency) may also be monitored, via theelectrode128. This could be monitored continuously to highlight the cardiac impedance cycle. In this regard, it is believed that each region within the heart has an unique cardiac impedance and will have distinct characteristics. The cardiac impedance would, therefore, provide more information to be correlated with thesensors58 and thecatheter52 in determining the location of the lead tip and can act as an anatomical landmark. The impedance signal could also be used to help determine if the lead is floating or lodged against the heart tissue.

Another type of sensor, which can be placed at the tip of thecatheter52 is an absolute pressure sensor, which can monitor hemo-dynamics. The intra-cardial pressure signal is an important signal in diagnostics and critical care monitoring. As a consequence, the characteristics of the pressure signal are well characterized for each region of the heart. For normal hearts, each region is distinctly characteristic with the sharp transitions between the upper and lower chambers of the heart. Taken with theelectrode sensors58 information, the location of thecatheter tip120 can be determined with a further high degree of confidence. These transition regions between the chambers of the heart could also be used as registration data points for 3-D heart models, further discussed herein.

The fluoro-enhanced implant procedure provides the physician with real-time location information of thecatheter52. An icon representing thecatheter52 is superimposed on the background of a 3-D heart model or atlas model. The electrode and/or pressure sensor information discussed above is used to correctly locate the catheter position within this heart model. In this regard, very specific locations can be searched out to provide reference points within the heart to fit the model space. The transition between regions of the heart are easily identified through changes in the morphology of the electrode and pressure signals. The transition regions are very sharp, making these regions excellent reference points or landmarks for the heart model. The possible reference points include the superior vena cava (SVC) to right atria transition, the tricuspid valve, and the left ventricular apex. As these reference points are located, the heart model is shrunk or stretched and rotated to match these reference points. Normally, thenavigation system10 will automatically locate the reference points by monitoring the electrode and pressure sensors. This results in a visualization of thecatheter52 as it is moved through the heart model. Once the 3-D heart model placement is established, a mapping function can begin or a lead implant site chosen. The 3-D heart model will be scaled and rotated only within physiological bounds. Reference points outside of these bounds will generate an alert and require the physician to resolve the discrepancy.

An exemplary lead implant method orprocedure138 for identifying a lead implant site is illustrated inFIG. 6. Theprocedure138 includes alandmark identification process140 that includes n number of steps atblock142, which depends on the number of landmarks needed or recognizable for a particular application. Included in thisprocess140 is catheter navigation, viablock144, which provides position and orientation information that is measured in real time, via thesensors58 withincatheter52. As thecatheter52 is navigated, as set forth inblock144, additional data is gathered within the heart, via sensors positioned on thecatheter52 atblock146. As discussed, this additional data can include pressure, temperature, oxygen, impedance and electro-physiological information. By monitoring this additional data atblock146, landmarks or reference points within the heart can be identified and marked on the catheter fluoroscopic images atblock148. The process of collecting the landmarks can be a manual or automatic process by identifying the physical landmarks within the fluoroscopic image, based upon the received data fromblock146, that identify distinct points or regions within the heart.

Once the multiple landmarks or reference points are identified in the heart, a 3-D heart model or atlas heart model is superimposed over the fluoroscopic images or modeled as a 3-D volume view by registering or translating the 3-D heart model in relation to the landmarks collected atblock148. This fusion occurs atblock150, which translates, rotates and scales the 3-D heart model, based upon the collected landmarks to provide a patient specific heart model that can be used for various procedures. Again, the heart model can be generated from an atlas model, as set forth inblock152 or it may be generated from an actual physiological image, such as from an MRI or a CT. Once the 3-D model has been scaled and registered to the landmarks, the controller orwork station34 provides navigation and road map information to direct thecatheter52 through the heart to a suggested or estimated optimized target site for lead placement atblock154. This target site can be identified on the 3-D model along with a real time view of an icon representing thecatheter52 moving toward the suggested target site. In this regard, the physician would know where the target is on the 3-D map ordisplay36 and can simply navigate thecatheter52 toward this target. The target site can be based on statistical maps that can suggest where lead placement should take place, depending on the pathology of the patient.

In addition to identifying a potential target site for lead placement, thenavigation system10 can also suggest sites for drug or cell delivery. Alternatively, thecatheter52 can be used as amapping catheter52. Theposition sensors58 provide real time feedback on the catheter location in 3-D space, which is a requirement for accurate mapping. The mapping procedure is essentially an extension of the fluoro-enhanced implant approach, set forth inFIG. 6. Themapping catheter52 will be optimized for mapping and/or to implant, but the basic procedure remains the same.

Essentially, the 3-D heart model is calibrated using the same technique as shown inFIG. 6, and the correctly scaled heart model becomes the basis for the initial mapping grid. With a micro-motion catheter, further discussed herein, the catheter is positioned at each mapping site in a semi-autonomous fashion with user intervention as needed. For catheters without micro-motion, the system would highlight on thedisplay36, the next mapping point, along with the actual catheter position. The user or physician would then manually manipulate or steer thecatheter tip120 to the identified location. Alternatively, the physician or user may choose each location and initiates a mapping measurement for that point. With asingle electrode catheter52, the intrinsic electrical amplitude, pacing threshold, and wall motion (contractility) can be measured. As the mapping progresses, a 3-D diagnostic map of the measured parameters are displayed alongside the 3-D model display. This method of mapping provides the capability of highlighting and detailing a number of heart defects, such as chronic infarct, chronic ischemia, perfusion defect, or aneurism. If a mapping orEP catheter52 with multiple electrodes is used, such aselectrode128, this mapping system can generate and display inter-cardiac electrical activity and timing, along with exact catheter tip and electrode location in real time. The result is a 3-D electro-anatomical map reconstruction. The applications for this system includes mapping of ventricular and supra-ventricular arrhythmias, mapping of myocardial potential and conduction velocity, and depolarization mapping. Usingmultiple position sensors58, with eachsensor58 associated with an electrode on thecatheter52, thenavigation system10 can be used to accurately measure the location of each electrode measurement providing improved mapping accuracy.

In addition to using aguide wire118 to adjust or steer thecatheter52, micro-motion technology may also be used to precisely steer the catheter in an automated manner. In this regard, selective heating of a shaped memory metal enables and provides the ability to steer thecatheter52 or lead to a precise location. The micro-motion technology applies a VLSI film to a piece of shape memory metal to form an actuator. The VLSI film has a pattern of resistors in the range of 100-300 ohms. The film is attached to the metal and the electrode connections made to the computer controller, such as thework station34. A small amount of current is applied to one or multiple resistors, which generates a localized heating of the metal. This provides precise steering to a specific location within the heart. Also, a semi-automated mapping procedure can then take place to construct the electro-anatomical maps. In this regard, the micro-motion actuator is used to manipulate thecatheter52 to a desired set of mapping points automatically. With the addition ofposition sensors58, real time feedback of the catheter curvature provides improved steering capabilities. Should it be desired, strain gages may also be applied to the actuator to provide additional real time feedback of the curved position. For example, micro-motion technology is available from Micro-Motion Sciences, which provides a controllable and steerable catheter, via the selective heating of a shaped memory metal that passes through thecatheter52. Micro-electron mechanical sensor (MEMS) technology, as well as nano technology may also be utilized for controlling the manipulation and steering of thecatheter52.

Again, fluoro pre-imaging of the patient is initially completed using theimaging system12. Once completed, thenavigation system10 utilizes a three-dimensional volume rendered or wire frame model of the heart or other soft tissue that is registered to thepatient14. The heart model is scalable, morphed or registered using 2-D and 3-D image techniques to match the fluoro images and measured reference points are determined from the transitional signals on the electrical and pressure sensors associated with thecatheter52. Thenavigation system10 then displays the three-dimensional heart model on thedisplay36. An icon of thecatheter52 is simultaneously displayed in correct relation to the model and fluoro images. As the session begins, the model is positioned based on the known placement of thedynamic reference frame54 and the fluoro images captured by theimager12. Once thecatheter52 is in range, it is displayed on thedisplay36 relative to the rendered heart model. Simultaneously, multiple views of thecatheter52 and heart model are available on thedisplay36 to aid in visualizing the catheter shape and position within the heart.

During the initial model scaling, the electrical and pressure signals are continuously monitored and displayed. At the transition from the superior vena cava to the right atrium, the electrical and pressure signal morphology changes. This transition is noted by thenavigation system10, along with the catheter position at the time of the transition. This position represents a reference point for the heart model. The heart model is then repositioned to match this reference point. The physician is given full control over this process. If necessary, the physician can manually set any of the heart model reference points. This is accomplished by manually placing thecatheter52 at the desired reference position and selecting the appropriate model reference point. This same process is repeated as thecatheter52 passes the tricuspid valve and into the right ventricle. This transition point marks an additional reference point for the model. At these reference positions, the model is stretched, rotated, and aligned to match the reference locations. A third reference point is the left ventricular apex. At this point, the physician should be able to easily manipulate thecatheter52 into the apex or mark this as a reference point.

At this point, thenavigation system10 displays a very accurate visual representation of the catheter placement within the heart model. The visual feedback allows the position and orientation of thecatheter52 to be manipulated with a high degree of confidence and accuracy. The 3-D model includes statistical atlas information that can be provided to the physician for improved outcome. The potential implant sites can be tested for good electrical characteristics and optimal sites selected. Thecatheter52 is then used to guide the lead to the chosen site. A final fluoroscopic image can then be taken to assess excessive lead motion and lead tension.

It should also be noted that as long as thedynamic reference frame54 is not moved, thecatheter52 can be re-introduced without needing to rescale the 3-D heart model. The calibration of the heart model is maintained. In this same way, a secondary catheter could be introduced with no loss and accuracy. Once the 3-D heart model is scaled and positioned, it remains accurate throughout the procedure.

Referring toFIG. 7, anexemplary image156 that is displayed ondisplay36 is illustrated. In theimage156, anicon157 representing the position and location of thecatheter52 is shown navigating through the superior vena cava. In order to provide a road map to guide or suggest a possible path for thecatheter52, atarget158 may be illustrated and superimposed onto the pre-acquired image, as shown atreference numeral158. At thisspecific landmark158, data can either be manually or automatically downloaded from other sources, such as the catheter, lead, or pacemaker programmer to create a hyperlink with this virtual annotatedlandmark158. By a simple mouse click (red arrow160), all available data could be displayed by a pop-upwindow162. This data includes information, such as temperature, pressure, oxygen level, or electro-physiological signals, as shown inwindows162. As such, a user or physician would simply refer to the virtual annotatedlandmarks158 in the particular view and click on thatlandmark158 to obtain the physiological information at that particular site. Thecatheter52 will thus gather, store, and download data on patient morphology, electrical thresholds and other implant parameters that can be stored for later review.

Thecatheter52 may also optionally be fitted with a fiberoptic imaging sensor. Fiberoptic imaging technology is available, for example, from Cardio Optics of Boulder, Colo., which enables a catheter to view the heart and heart structures continuously through blood. This enables the physician or user to have an additional view of what is in front of thecatheter52, which can be displayed ondisplay36.

Turning toFIG. 8, an additionalexemplary image164 that is displayed ondisplay36 is illustrated. Theimage164 includes anicon166, representing the position and location of thecatheter52. Theicon166 has an enlarged probe diameter as compared to theicon157, shown inFIG. 7. This probe diameter of theicon166 representing thecatheter52 is adjusted by way of probe diameter adjustment switches168. By pressing the “+” button of the probe diameter switches168, the probe diameter increases. Conversely, by pressing the “−” button, the probe diameter decreases. This enables the surgeon to adjust the probe diameter to a desired size providing further or enhanced visualization of the surgical procedure.

Referring now toFIG. 9, anexemplary image170 that is displayed ondisplay36 is illustrated. Theimage170 includes anicon172 representing the location and position of thecatheter52. Theicon172 further includes astraight projection portion174 that projects straight along the direction of thefirst sensor58 within thecatheter52. Thisstraight projection174 represents a straight projected trajectory of thecatheter52. The length of the projectedicon portion174 may be adjusted via projected length switches176. Here again, the “+” button lengthens the straight projectedicon174, while the “−” button shortens the projected length of theicon174. This estimated straight trajectory enables the surgeon to determine where thecatheter52 is traveling and how far or how much travel is necessary to reach a desired target along a straight path.

Turning now toFIG. 10, anexemplary image178 that is displayed ondisplay36 is illustrated. Theimage178 includes anicon180 representing the position and location of thecatheter52. Theimage178 further includes a spline orcurved projection182, which is based upon the shape of thecurved catheter52, shown asicon180. Here again, the projected length of thespline projection182 is controlled by way of the projected length switches176. This estimated curve projection enables the surgeon to determine where thecatheter52 will travel if thecatheter52 continues along its curved trajectory, further providing enhanced features for the surgeon navigating thecatheter52. The estimated curve is determined by use of known curve fitting algorithms that are adjustable based upon the type of catheter used and based upon the flexibility and material of thecatheter52. This enables estimated curved trajectories of thecatheter52 to be displayed to assist the user.

Referring now toFIG. 11, an exemplary method or procedure184 for navigating thecatheter52 to the coronary sinus region of the heart is illustrated. The procedure184 begins atblock186, where thecatheter navigation system10 is set up. This set up includes connecting all of the appropriate hardware within thenavigation system10, as well as activating the various computers within thesystem10. Once thenavigation system10 is set up atblock186, the procedure184 proceeds to acquire an empty image atblock188. The acquisition of the empty image of theblock188 is similar to thecalibration process68, shown inFIG. 3. In this regard, an x-ray is taken by theimaging device12 where intrinsic calibration is performed on this empty image to calibrate theimaging device12.Radiation sensor24 senses when the x-ray process has taken place atblock190. The resulting empty x-ray image is shown ondisplay36 and illustrated atblock192, which illustrates the calibration and trackingtarget22. Again, the calibration process is an optional process depending on the medical procedure conducted or depending on the type ofimaging system12.

Once thenavigation system10 has been calibrated, thepatient14 is positioned within theimaging device12 to capture various views of thepatient14. Atblock194, an anterior/posterior anatomic image of thepatient14 is acquired by theimaging device12. The image acquisition atblock194 may be gated viablock196 using theECG62 to trigger when the acquisition of the anterior/posterior image is acquired. The image acquisition may also be gated by any other physiological event. The anterior/posterior anatomic image of the coronary sinus region is shown atdisplay198. Once the anterior/posterior image is acquired atblock194, the lateral anatomic image of thepatient14 is acquired atblock200. Again, this image acquisition atblock200 may be gated, viablock196. The lateral image is shown indisplay block202.

Once the anterior/posterior anatomic image is acquired atblock194 and the lateral anatomic image is acquired atblock200, the procedure184 proceeds to block204 where the acquired images are activated. In this regard, each image is displayed ondisplay36 as is shown inblocks198 and202. Once the images have been activated atblock204, the procedure proceeds to block206, where thecatheter52 is navigated to the coronary sinus. To assist in this navigation of thecatheter52, atlas, template and additional information, viablock208 may be provided. The atlas information may include registering a three-dimensional atlas heart model, as shown inFIG. 12, similar to the way discussed inFIG. 6, to assist in navigating thecatheter52 to the coronary sinus. Templates may also be superimposed over theimages198 and202 or over the three-dimensional heart model to provide a map for steering and guiding thecatheter52 through the coronary sinus region. The additional information provided atblock208 can also include an algorithm that is designed to direct the surgeon through various steps suggesting or estimating where the surgeon should be looking to guide thecatheter52 through the coronary sinus region. These steps may include providing various guide points within the template that identify on thedisplay36 where thecatheter52 should be navigated. As thecatheter52 reaches a particular suggested guide point, thesystem10 can then prompt the surgeon to then go to the next guide point, thereby providing a roadmap to the surgeon through the coronary sinus region. The algorithm for locating the coronary sinus can increase the accuracy of pacing lead placement significantly, thereby providing reduced surgical time and increased accuracy and efficiency.

Referring toFIG. 12, animage210 illustrating a three-dimensionalatlas heart model212 is illustrated. In theimage210, anicon214 of thecatheter52 is illustrated passing through theheart model212 to acell delivery region216. Theregion216 can be highlighted on theheart model212 to guide the surgeon to a particular region of the heart and, in this example, for cell delivery therapy. Again, theheart model212 can also be used for any other cardiac procedure to assist the surgeon during pacing lead placement, ablation, stenting, etc.

Turning now toFIG. 13, anotherexemplary method220 for navigating a pacemaker lead placement in the heart using acatheter52 or other instrument is illustrated. The method orprocedure220 is directed to performing image guided coronary sinus cannulation or any other procedure using thenavigation catheter52 or any other instrument in order to position the left heart lead at an optimal site. Thenavigation system10 employs thenavigation catheter52 or any other instrument, such as insert or guide wire that carries one or more of thelocalization sensors58, to provide information to the user, viadisplay36. Themethod220 begins atblock222 where the particular organ or region of interest is identified. Any organ or soft tissue or region of the patient may be navigated using this disclosed method or procedure. As an exemplary procedure, the coronary sinus region of the heart will be described in further detail.

Once the organ or the heart has been identified, external or internalfiducial markers60 may be placed on the heart atblock221. Alternatively, any type of anatomical landmark may also be used as the fiducial marker. Still further, contours or paths within the navigated organ may also be used as fiducial markers for the registration process. The procedure then proceeds to block224 where image acquisition on this region of the patient is conducted. Again, the image acquisition can be from any type of imaging device and can be performed pre-operatively or intra-operatively using afluoroscope12, shown inFIG. 1 or any other imaging devices, such as an ultrasound, MRI, CT, etc. Theimage acquisition process224 may also be gated, viablock226 to a particular anatomical function. For example, ECG gating using theECG62 device may be utilized during theimage acquisition224 to insure that the image is captured or image data is used at a particular sequencing point, viaECG gating226. In other words, the image may be captured at a particular point or time in a cycle or alternatively if real-time image data is captured over time, image data at a particular point along the time frame may be used, viaECG gating226. By providingECG gating226, thenavigation system10 is able to track the instrument orcatheter52 that is synchronized with the pre-acquired images. In other words, this enables synchronization of the pre-acquired image with the instrument during navigation so that the virtual representation of the instrument orcatheter52 is aligned with the pre-acquired image.

Again, it should be noted thatimage acquisition process224 may be gated atblock226 to capture a specific image at a specific time or alternatively, the image data can be a streaming image data continuously captured and thegating226 may be used to capture image data at a specific time or frame of the already captured image data in order to track thecatheter52. TheECG gating technique226 also may include gating from any other physiological activity, which is directly or indirectly sensed, via thecatheter52 or other external sensors not associated with thecatheter52. Other types of physiological parameters or activities that can be sensed or used duringgating block226 include blood flow, electrophysiological, respiratory, cardiac, oxygen sensing, CO₂sensing, etc.

Any soft tissue navigation can benefit from gating or synchronizing to an anatomical function, such as the heartbeat, respiratory, etc., as previously discussed. For example, referring toFIGS. 14aand14b, a pre-acquired fluoroscopic image of the heart is illustrated with a virtual representation of thecatheter52. As shown inFIG. 14a, the fluoroscopic image of the heart acquired with a real catheter is identified asreference numeral228. The virtual representation of the navigatingcatheter52, is shown as reference numeral230. The superimposed catheter230 does not matchcatheter228 because it is not synched with the originally capturedimage228. In other words, when thepre-acquired image228 was captured, it was arbitrarily captured and not gated to a specific physiological event. Therefore, when the superimposed catheter230 was localized to the pre-acquired images, it resulted in a mismatched or unsynched image. In contrast, referring toFIG. 14b, using theECG gating technique226, since thenavigation system10 knows when theimage228 had been acquired in the particular heartbeat cycle, it is possible to sync the superimposed or virtual representation of theinstrument232 with theimage228 to generate a good match.

Returning toFIG. 13, atblock234, one or multipledynamic reference frames54 are affixed to thepatient14, either internally, via a lead or externally, with an adhesive patch on the skin. Thedynamic reference frames54 may also includefiducial markers60, as previously discussed and used for the registration process.

Images of the navigated organ, such as theheart222, are acquired atblock224 during theprocedure220. Each of the images acquired atblock224 is registered to the patient atblock236, either manually using fluoroscopy, ultrasound, or other known techniques by usingfiducial markers60 that can be located on the pre-acquired images. Alternatively, if thefiducial markers60 contain EM position sensors then automatic registration is possible. An exemplary sensor that includes both a dynamic reference frame and a fiducial marker, is set forth in U.S. Pat. No. 6,381,485, entitled “Registration of Human Anatomy Integrated for Electromagnetic Localization”, issued Apr. 30, 2002, where is hereby incorporated by reference. In a case of pre-operative or intraoperative imaging, such as cardiac-gated MRI or CT, the registration may also be gated at the same event during the heart cycle to optimize the registration accuracy atblock226.

There are various types of registration procedures to be utilized that can be optionally gated, via theECG gating226. Again, patient registration is the process of determining how to correlate the position of the instrument orcatheter52 in the patient14 to the position on the pre-acquired or intra-operative acquired images. There are typically four different ways of registering the position of thecatheter52 in relation to the images acquired atblock224. The first registration procedure is point registration. With point registration, the pre-operative images acquired may be synchronized by theECG gating block226. To manually register thepatient14, the physician will select landmarks or particular points identified in the pre-acquired images and then touch the corresponding points in the patient's anatomy with thepointer probe66. By selecting the internal or external landmarks on the anatomy orfiducial markers60 that are identifiable in the pre-acquired images, it is possible to establish a relationship with the coordinate system for navigation. To perform an automated point registration process, thefiducial markers60 may also include the dynamic reference frames54.

The second type of registration is a surface registration technique. This technique is substantially similar to the point registration technique, except that thepointer probe66 or thecatheter52 is dragged or passed along the patient's anatomy, either internally or externally. By using surface recognition software, as is known in the art, the navigated surface can be automatically matched with the corresponding surface in the pre-acquired image. Again, to increase accuracy further, this registration technique may also be synched to when the pre-acquired image was captured, viablock226.

Another technique for registering two different modalities is by a path registration technique using theEM catheter52. When theEM catheter52 penetrates a specific region in the anatomy, such as a vein, it is possible to store the location of thesensors58, along the path by collecting the sensor data in synchronization with the heartbeat time (ECG gating226). A virtual 3-dimensional curve can then be built to represent an actual cavity or vessel. Using known pattern recognition or distance map algorithms, it is then possible to locate and find the specific shape of that curve in the pre-operative scan or image and get an automatic path registration.

Examples of types of catheters used for the path type registration technique include spiral or balloon catheters, as illustrated inFIGS. 15a-15cand16, respectively. As shown inFIG. 15a, aspiral catheter238 is illustrated that includeselectromagnetic coil sensors58 positioned spirally within the inner surface of thevein240. The advantage of the spiral catheter, is that there is no blood obstruction within thevein240 and no risk of balloon deflation issues.FIG. 15billustrates the data collection andvirtual 3D curve242 that is constructed from the sensed signals, via spirally orientedsensors58. The virtual 3-dimensional curve244 is illustrated inFIG. 15c, which represents the final 3D shaped vessel, based on thecurve242, which represents the vein that is to be matched with a segment vein in the pre-operative or intraoperative scan.

Turning toFIG. 16, aballoon catheter246 that includes a plurality ofballoons248, each having sensor coils58 located therein, is illustrated. Here again, theballoons248 fit in thevein250 and center thecoils58 to match the 3-dimensional shape of thevein250. Here again, this enables a final 3D shape of thevein250 to be modeled and matched with a segmented vein in the pre-operative scan or intraoperative scan.

Another type of registration process, as previously discussed, involves the 2D/3D registration of a fluoroscopic image and a pre-op scan, which are each synchronized using theECG gating technique226. With both modality images acquired at the same time during a heartbeat, both images are then static and potentially matchable. This non-invasive method merges the 3D pre-operative scan with the 2D image. One way to automatically register the heart with fluoroscopy and CT or other imaging modality is to use the spinal vertebrae that is next to the heart itself as the anatomical landmark. The thoracic vertebrae are key landmarks to get the automatic 2D to 3D registration. In the alternative, angiography and the use of vessels themselves for registration between both modalities may also be utilized. Alternatively, known 3D to 3D or 4D to 4D registration may also be employed.

Returning toFIG. 13, once the image acquired during theimage acquisition phase224 has been registered to the patient atblock236 usingECG gating techniques226, the procedure proceeds to block254 where the instrument orcatheter52 is tracked using thenavigation system10. Again, thenavigation system10 utilizes theelectromagnetic tracking system44 or any other type of tracking system, such as optical, acoustic, conductive, etc. From thetracking block254, theprocess220 includes block256 that identifies the electromagnetic instrument, such as thecatheter52 or guide wire that is being tracked in thetracking block254. Again, theinstrument52 may either receive or transmit electromagnetic signals enabling thetracking system44 to identify the location of theinstrument52 relative to thepatient14 and relative to the pre-acquired images during theimage acquisition block224, via theregistration block236. This enables navigation of thecatheter52 or any other instrument relative to the pre-acquired images atblock258. Again, once the images fromblock224 have been registered atblock236 and synchronization, via ECGgated block226, thenavigation catheter52 is inserted into one of the patient's organs, such as the heart, viablock222 and its virtual representation is displayed on the images, viablock258.

Upon navigating thecatheter52, viablock258, theprocedure220 proceeds to block260 where the procedure to find an optimized lead placement site is conducted. As an input to thissite selection procedure260, additional sensors may be embedded in thecatheter52, in order to provide cardiac or anatomic function measurements, via internal sensors atblock262. These additional sensors may include an electrophysiological (EP) tip, pressure sensors, temperature sensors, accelerometers, Doppler transducers, tissue sensors, spectroscopy sensors and trackingsensors58. By using the real-time data received from these sensors in association with the navigation images, thenavigation system10 assists the physician to identify key landmarks or estimated optimized sites on theimages224, such as the coronary sinus. The landmark selection may be manual or automatic by collecting and storing the information of the points on theimage224. Additionally or alternatively, thenavigation system10 may display one or more multiple color coded maps, viadisplay36, based on the data each sensor communicates to thenavigation system10. For example, temperature maps can be overlaid in real-time on theimages224, based on the temperature, thecatheter52 temperature sensor transmits. Also, the EP signal can be assigned to the collective points to assist the physician to make a decision where the coronary sinus is or is not.

Further information that can be delivered atblock262 includes a catheter or instrument information. In this regard, various catheters or instruments have flexibility or bending parameters, which enables different types of catheters to be navigated to different types of sites. This is sometimes referred to as a tortuocity factor. Navigating through a tortuous vascular structure generally requires a catheter to be very flexible and bendable without fracturing or failure. This type of information may also be delivered, viablock262 to insure that the proper catheter is being utilized to be navigated in the appropriate site. If it is determined that the site is too tortuous for the particular catheter utilized, the system will identify this to enable the surgeon to select a more appropriate catheter or instrument, via the tortuocity factor.

Multiple EM catheters52 may also be utilized and positioned on the left and right side of the heart to track the motion of the left and right side of the heart in order to optimize the heart function and pacing performance. In this regard, both sides of the heart are tracked to insure that they are balanced in order to have the proper flow, thereby optimizing the lead placement based on knowing this balance.

Moreover, if theimage acquisition224 is based on an ultrasound image, or if the catheter includes an internal ultrasound transducer sensor then Doppler information is available to provide hemo-dynamic data relative to the position. In this regard, the hemo-dynamic information enables a physician to calculate ejection fractions in the cardiac area to determine the volume of blood and flow through the heart using the Doppler technique. By measuring the volume of blood moving in and out of the chambers, this also provides further cardiac or physiological measurements in order to optimize the lead placement, via the information provided atblock262. In other words, by using a dynamic 3D ultrasound imaging modality or a Doppler sensor in thecatheter52, this enables a physician to visualize the anatomy in space over time. This spatio-temporal Doppler technique is useful for the hemo-dynamic studies and enables calculation of the ejection fraction in the cardiac area. By combining both anatomy information, hemo-dynamics from real-time spatio-temporal echography, localization and navigation technology to select an optimum lead placement atblock260, it is possible to significantly improve pacing performance and thus, patient outcome.

Thus, site selection atblock260 for the lead placement is optimized by providing an estimated optional site based on real-time anatomic or physiological information, navigation or localization information, hemo-dynamic data, and electrophysiological data, as opposed to simply stuffing the lead into the heart without any optimization. By improving the pacing performance of the therapy, the muscle is paced in its more normal function and overall heart function is improved. In contrast, if lead placement is not optimized, the heart may not function properly, thereby degrading other areas or muscles in the heart as they try to compensate for non-optimized performance.

An additional input to thesite selection block260 is a multi-patient database storage oratlas264 that provides previously acquired patient information or an atlas template on the estimated lead placement site. This atlas can be created by recording information used during the lead placement procedure, based on the anatomy and functional data atblock262. This atlas template atblock264 may provide an estimated target that can be visualized on thedisplay36 as thecatheter52 is navigated during thesite selection process260. Also during the current procedure, this information is stored and recorded atblock264 to update and improve the atlas template. In other words, as you are collecting all of this information during theprocedure220, an atlas is created atblock264, which can then determine and give estimates of what the most likely and best place for lead placement is. The ultimate outcome is trying to locate the best location for lead placement in order to provide the best performance for the heart. For example, assuming that one hundred previous procedures on one hundred patients have been performed and the information was recorded during these procedures that identified the path and sites where the leads were placed for optimized performance, for the one hundred and first procedure, the physician will use the previously acquired one hundred procedures to further optimize the results. This will provide a path to guide the physician to an estimated optimized site, which can be accessed via the site selection process atblock260.

Based on the multiple maps (position EP, speed, temperature, hemo-dynamic, etc), the physician can identify the coronary sinus osteum and cannulate the coronary sinus. In this regard, atblock266, thecatheter52 is guided to an estimatedinitial site location268, via the sitelocation storage block270 that stores the estimated sites using information fromblocks262 and264. Once in the coronary sinus, a contrast agent may be administered through thenavigation catheter52. Images of the coronary sinus can be acquired to create a new road map for lead placement. Again, these images can be gated or not, and acquired in 2D, 3D or 4D. Once the revised or updated road map is established and registered atblock236, the instrument, such as thecatheter52 or guide wire is used to select the branch for lead placement, viablock272 and target orsite274. During this procedure, thecatheter52 is pushed and visualized a real-time using images acquired during the contrast agent use. Again, in the coronary sinus osteum to the end lead placement site, this path is stored with thepatient database264 and will be displayed as an overlay on the image for future reference.

Once thebranch274 has been selected, vianavigation system10, an optimal site for the lead is selected atblock276 identified by estimated target orsite278. By tracking the catheter displacement with theposition sensors58 and by pacing the left heart, it is again possible to optimize the function of the heart. Also, with additional right heart catheter sensors, the overall cardiac function can be optimized, based on accelerometry gathered from the position sensors on both sides of the heart and by real-time measuring of the cardiac wall motion, thereby optimizing thelead site278. Also, by using the other sensors or other imaging modalities, such as the ultrasound or Doppler, via either an ultrasound imaging device or Doppler sensor in thecatheter52, hemo-dynamic information is gathered. This information is also used to provide an optimizedlead site278. This optimizedsite278 may be estimated and identified, via thetarget278 or selected by the physician upon reviewing all of the information, viablocks262 and264.

Once theoptimal site278 of the lead placement has been selected, the location and path is stored in a computer and displayed onimage280. The lead can then be placed over the guide wire or through thecatheter52 and directed to the desired optimizedsite278. A final check on the performance is evaluated before theprocedure220 is ended. In the event of a failure, lead dislodgement or other cause, the storedpath280 that has been acquired during the implantation procedure can be reused as a road map for the new lead placement. This can also be used and overlaid on future pre-acquired images as a 3D surgical road map for future patients.

Other uses of theprocedure220 may include an electromagnetic guidedbiopsy catheter282, illustrated inFIGS. 17aand17b. In this regard, every heart transplant patient undergoes an annual check-up to measure for early indicators of organ rejection in order to determine and confirm that the heart is still not rejected by the patient's body. These indicators include white blood cells, chemical charges, blood oxygen labels, etc. To make this determination, an endovascular biopsy catheter is inserted into the heart and multiple biopsies are performed in the septum wall of the heart between the left and right side of the heart. In conventional tests, a fluoroscopic procedure is performed utilizing contrast agent and continuous fluoroscopic images are used to select approximately ten biopsy samples in the septum. Again, this leads to exposing the patient to radiation and contrast agents, which is undesirable. By providing an EM guidedbiopsy catheter282, the procedure can be optimized and radiation and contrast agent use can be reduced or eliminated all together following the procedure similar to that disclosed inprocedure220.

Thecatheter282 is similar to a standard endovascular biopsy catheter that includes aflexible shaft284 having adistal biopsy end286 with a plurality ofbiopsy graspers288 to engage and capture a biopsy sample. Located at the proximal end of thecatheter282 is a fixedhandle290 and amovable portion292, which articulates thegraspers288. Located within theshaft284 are a plurality ofelectromagnetic sensors294 that operate similar to thesensors58 in thecatheter52. In this way, the shaft and the distal end of thecatheter282 may be tracked via theelectromagnetic tracking system44.

By utilizing the techniques set forth in theprocedure220, shown inFIG. 13, along with the electromagnetic guidedbiopsy catheter282, the distal end of thecatheter282 may be precisely guided to optimum sample sites in the septum without the constant radiation exposure and reduced or eliminated use of contrast agents. Moreover, by again building a database to create an atlas map, various optimized sample site locations can be identified in the pre-acquired images, so that thecatheter282 can simply be navigated to these sample sites to gather the biopsy tissue. Thus, only a couple of images are required to perform this task instead of using constant radiation to visualize the biopsy catheter and a more precise sampling can be achieved. It should further be noted that thebiopsy catheter282 may be utilized to biopsy other areas of the patient as well, such as the spine, cervical or other regions of apatient14.

Theprocedure220 may also be used for a catheter-based approach using thenavigation system10 to treat neurological disease. In this regard, today most of the neurological diseases are treated and accessed from the cranium down to the neurological site in order to treat diseases, such as tumors, ventricle blockages, Parkinson's, aneurysm, etc. However, this type of treatment results in significant trauma due to forming a skull hole, dura opening, fiber destruction, or other cerebral structural damage. Also, cell, drug, or gene delivery generally cannot be taken orally because the product delivered is destroyed by the digestive system. Therefore, site specific delivery is needed. A minimally invasive navigation approach is possible since all cerebral structures are accessible from either vascular or cerebrospinal fluid tree (CSF) access. By using thecatheter52 equipped with theEM sensors58 that can be tracked by theEM tracking system44 and by using theimage registration techniques236 to overlay the position of thecatheter52 onto a pre-operative (CT, MRI, etc.) and or intra-operative (fluoroscopy, ultrasound, etc) images, thecatheter52 may be steered from the jugular, groin, or spine all the way to the neurological site, via the endovascular or the cerebral fluid tree path. At the neurological site, treatment can then be delivered and provided.

For example, site specific therapy can be delivered, such as gene, drug, or cell delivery at the site specific area. For aneurysm treatment, a site specific biologic or embolic treatment can be delivered to attempt to correct the aneurysm. With Parkinson's disease, lead placement through the third and fourth ventricle using the cerebral fluid tree is possible. At the caudate nucleus, a biological patch delivery using the cerebral fluid tree is also possible. The procedure may also be used for shunt placement to correct an occlusion. Here again, instead of drilling a hole, a minimally invasive approach through either the endovascular or cerebrospinal tree is an option. Again, these types of neurological procedures may also be optimized by sensing various surrounding anatomical functions with thecatheter52 or other instrument to again optimize lead placement or optimize gene, cell or drug delivery by providing an estimated delivery site.

Turning now toFIGS. 18aand18b, a prior art intravascular ultrasound (IVUS)catheter296 is illustrated. TheIVUS catheter296 is a disposable catheter that includes anultrasound transducer298 that is typically used to visualize tissue and/or blood vessels in a minimally invasive approach. TheIVUS catheter296 is a disposable catheter that is also very costly. Thetransducer298 enables visualization only from aside view plane300 and does not provide aforward view302 whatsoever. Thesingle side view300 is available with thecatheter296 positioned statically. Should theIVUS catheter296 be rotated aboutarc304, as illustrated inFIG. 18b, various side view planes300,300′, . . . are available about therotation axis304.

Referring now toFIG. 19, a virtual intravascular ultrasound (IVUS)catheter306 according to the teachings of the present invention is illustrated. Thevirtual IVUS catheter306 includes at least oneelectromagnetic tracking sensor308 or multiple tracking sensors positioned along its shaft to again track the location of thevirtual IVUS catheter306 with theelectromagnetic tracking system44. Again, it should be noted that any other type of tracking system and sensors may also be utilized. Thevirtual IVUS catheter306 is able to generate virtual IVUS views from an infinite number of planes ordirection310,310′,310″ from any angle or position relative to thecatheter306, further discussed herein.

Referring toFIG. 20, avirtual IVUS system312 according to the teachings of the present invention is illustrated, which includes thevirtual IVUS catheter306 having thesensor308. Thevirtual IVUS system312 works in combination with thenavigation system10 and employs theelectromagnetic tracking system44. With this type of configuration, an ultrasound imaging modality may be used to replace thefluoroscopic imaging device12 or theimaging device12 may be used in combination with the ultrasound imaging modality. In this regard, a dynamic3D ultrasound probe314, such as the Phillips XMatrix probe, combined with anelectromagnetic tracking sensor316 is positioned outside the body of thepatient14 and connected to anultrasound controller317. Theultrasound controller317 may be a separate controller or combined with thework station34 andcoil array controller48. By using the3D probe314 with theelectromagnetic sensor316, the field of view of theprobe314 is calibrated to the EM coordinate system of theelectromagnetic tracking system44. By tracking theflexible EM catheter306 equipped with at least oneelectromagnetic sensor308, thecontroller317 can generate a virtual IVUS view from that coil position, as illustrated inFIG. 19. In other words, the dynamic 3D ultrasound imaging modality from the3D ultrasound probe314 allows a physician to visualize the anatomy in space over time. By tracking theflexible catheter306 equipped with at least threeEM coils308, it is possible to superimpose thecatheter306 onto this spatio-temporal echographic image. The three coils of thecatheter306 represent the planes in the space over time from the perspective of thecatheter306. The equation of those planes may then be calculated to display the corresponding echographic spatio-temporal plane to visualize thecatheter306 in its entire shape in a real-time echographic image or from the point of view of the catheter.

Therefore, by providing a very costeffective catheter306 that does not include an ultrasound transducer in the catheter, but uses theexternal ultrasound probe314, virtual IVUS images can be produced and displayed at any angle or direction relative to thecatheter306 or from the catheter's point of view. This enables the physician to superimpose thecatheter306 onto theimage318, illustrated ondisplay36, as well as generate a field of views from the forward position of thecatheter306. The system also operates to either take a slice of the 3D ultrasound relative to its current location or it may also identify and generate a view of its total path that the catheter or instrument has traversed through. Thesystem312 also provides a look ahead view as it moves relative to thecatheter306. Basically, thesystem312 creates slices based on the vessel position and views transverse to the vessel or axial to the vessel along curved paths or straight paths. Projected trajectories of the forward advance of thecatheter306 can also be tracked and superimposed on theimage318. It should also be noted that while a3D ultrasound probe314 has been discussed, a 4D probe or other imaging modalities, such as MRI, CT, OCT and spectroscopy may also be utilized to create the virtual views. Thus, by automatically registering theprobe314 having thesensor316 relative to thecatheter306 having thesensor308 using thenavigation system44, automatic registering between these two systems without requiring motion correction is available. Moreover, the ultrasound image, which is registered via theprobe314 andcatheter306, may also be registered or linked with any other image modalities. In this regard, the ultrasound image modalities may be registered relative to fluoroscopic, MRI, CT, or other image modalities and displayed at one time on thedisplay36 to provide a further level of information.

In addition to providing a three-dimensional image volume, theultrasonic probe314 may also provide a three-dimensional Doppler volume by switching theultrasound probe314 to the spatio-temporal Doppler format. From this Doppler volume, the physician can visualize a metric or statistical measurements for blood flow or motion at the tip of thecatheter306. Again, this system would then not be visualizing an ultrasound image, but visualizing statistics or measurements. This information can be conveyed using color coded figures that are displayed on thedisplay36. For example, should thecatheter306 be guided through a blood vessel and the Doppler effect measure the volume of blood flow going through the vessel at a certain point, where there is an occlusion, there would be much smaller blood flow on one side of the occlusion than on the other. The quicker blood flow can be characterized by red on one side of the vessel and blue on the occluded side, thereby identifying where the occlusion is within the vessel. Other anatomical functions may also be sensed as previously discussed, such as pressure, temperature, etc and also visualized on thedisplay36. This again enables thenavigation system10 to identify an estimate site to navigate to and deliver a therapy (e.g., ablation).

In addition to navigating and visualizing the area of interest, thecatheter306 or other instrument may also deliver therapy at the point of interest. For example, thecatheter306 may delivery a drug, ablate, or deliver a lead or other device following theprocedure220. With drug delivery, a profusion model may be overlaid over the tracked image that models the flow of the drug depending on the dosage and type of drug delivered. This overlay can be color coded to identify the region that the drug will interact at the area of interest. Also, by providing sensors at thecatheter306, real-time monitoring of the drug delivery may also be visualized on thedisplay36, thereby providing real-time feedback on the diffusion through the tissue of the drug delivery. In this way, proper dosage of the drug delivery is achieved. These templates can also identify therapy effective zones, such as ablation zones in the area that the ablation may affect before the ablation is performed. This also provides an optimized procedure.

With all of the identified procedures, a dual delivery therapy may also be provided. For example, with drug therapy, some drugs require stimulation to activate the drugs, such as by heat, while other drugs may require a second drug to activate. Thus, the instrument or catheter utilized to navigate to the particular optimized site can both deliver the drug and also heat it using a heat probe or deliver a second drug in order to activate it and provide better performance. The drug delivery may also include magnetically conductive components, so that the pattern or direction of where the drug delivery is applied is controlled, via a magnetically sensitive sensor attached to the catheter. The drug delivery or any other type of delivery, such as cell or gene delivery may also be gated or synched to an anatomical physiological function, such as the heartbeat, via the ECG monitor62 or other devices. In this way, by gating the delivery to the particular cycle, proper placement and dosage of the drug, gene or cell delivery is also optimized.

The instruments may also deliver the drugs, genes or cells using a pattern delivery technique. With this type of technique, drugs may be delivered over a significant area. For example, a 9×9 grid spaced about 0.1 millimeters apart may be the delivery area. Thecatheter52 may be provided with multiple delivery needles, such as 3×3 grouping of needles, thereby requiring only nine deliveries to fill the 9×9 area. This again delivers the drug to the needed area, thereby optimizing the result of the drug delivery and reducing the time for delivering the drug. Moreover, the catheter may also include a sensor to provide additional feedback on the delivery to again identify that a sufficient amount of drug has been delivered. In which case, the delivery plan may be able to be changed using this real-time feedback. This delivery plan can again include an icon representing where the drug delivery should take place that is determined by thenavigation system10.

Referring toFIGS. 21-23, an exemplary catheter, along with a delivery insert, which may be used with the navigation system and procedure disclosed herein is discussed in further detail. As illustrated inFIG. 21, acatheter326 is illustrated to include adelivery tube328 and ahandle330 that defines apassage332 in communication with thetube328. As shown inFIG. 22, amulti-sensor insert334 is illustrated that includes four sensor coils336. Theinsert334 is electronically in communication with thenavigation probe interface50, similar to thecatheter52 illustrated inFIG. 1. Theinsert334 is operable to be slidably inserted withinpassage332 defined inhandle330 in order to pass intodelivery tube328, as illustrated inFIG. 23. Theinsert334 enables the use of various conventional catheters, such as thecatheter326 without requiring further modification to existing catheters. In other words, use of theinsert334, havingelectromagnetic sensors336 enables conventional catheters to be converted to a navigable tracked catheter by simply passing theinsert334 within thecatheter326. Theinsert334 includes acannula338 to enable delivery of various therapies through thecatheter326 and insert334 once theinsert334 has been navigated to the appropriate site, via thecatheter326. For example, a lead may be passed through the cannulation of theinstrument334 during a cardiac lead placement, as previously discussed.

The description of the invention is merely exemplary in nature and, thus, variations that do not depart from the gist of the invention are intended to be within the scope of the invention. Such variations are not to be regarded as a departure from the spirit and scope of the invention.

Claims (31)

1. A system for guiding an instrument through a region of a subject, comprising:

a non-imaging instrument configured to be moveable through the subject;

a first tracking device connected near a distal end of the instrument;

an ultrasound imaging system to generate an image of the subject;

a second tracking device associated with the ultrasound imaging system;

a tracking system to track the first tracking device within the subject and the second tracking device;

an external imaging system configured to be external to the subject and of a different imaging modality than the ultrasound imaging system; and

a display device, wherein an instrument image is generated based on the tracked location of the first tracking device, the second tracking device, and the generated image;

wherein a second image generated with the external imaging system and the instrument image is registered to the subject and one another and displayed at one time on the display device.

2. The system ofclaim 1, wherein the first tracking device includes at least one coil, wherein the tracking system is an electromagnetic tracking system.

3. The system ofclaim 2, wherein the instrument image is a perspective image from at least one perspective of the at least one coil.

4. The system ofclaim 1, wherein the generated image is a spatio-temporal echographic image.

5. The system ofclaim 4, wherein a tracked position of the instrument is superimposed on the spatio-temporal echographic image.

6. The system ofclaim 5, wherein the superimposed position of the instrument is at least a portion of a total path that the instrument has traversed through the subject.

7. The system ofclaim 4, wherein the first tracking device includes at least one coil, wherein the tracking system is an electromagnetic tracking system;

wherein the spatio-temporal echographic image is an instrument perspective image from at least one perspective of the at least one coil.

8. The system ofclaim 7, wherein the perspective image is a slice of the spatio-temporal echographic image generated of the subject.

9. The system ofclaim 1, wherein the first tracking device and the second tracking device are automatically registered relative to one another by being tracked by the tracking system in the same frame of reference and the instrument image is displayed without a need for motion correction.

10. The system ofclaim 1, wherein the first tracking device includes a plurality of first tracking devices spaced along a length of the instrument.

11. A system for guiding an instrument through a region of a subject, comprising:

an instrument configured to be moveable through the subject;

a first tracking device connected along the instrument;

a tracking system to track the first tracking device within the subject;

a navigation system in communication with the tracking system;

a dynamic three dimensional (3D) ultrasound probe configured to image the subject; and

a second tracking device configured to be positioned outside the subject and connected to the dynamic 3D ultrasound probe;

a display generation device configured to generate an image;

wherein the navigation system is operable to determine a relative position of the instrument and the dynamic 3D ultrasound probe based on tracked positions of the first tracking device and the second tracking device;

wherein a path of the instrument is displayed as a path icon superimposed on the image as an instrument path icon to display the path that the instrument has traversed through the subject.

12. The system ofclaim 11, further comprising:

an ultrasound controller;

wherein the dynamic 3D ultrasound probe is connected to the ultrasound controller.

13. The system ofclaim 12, wherein the ultrasound controller is combined with the navigation system.

14. The system ofclaim 13, wherein a field of view of the dynamic 3D ultrasound probe is calibrated to a coordination system of the navigation system.

15. The system ofclaim 14, wherein the navigation system is configured to determine a field of view from the instrument within the subject by tracking the first tracking device and tracking the second tracking device.

16. The system ofclaim 11, wherein the first tracking device and the second tracking device are both electromagnetic tracking devices.

17. The system ofclaim 11, wherein the image is a spatio-temporal echographic image.

18. A method for guiding an instrument through a region of a subject, comprising:

tracking an instrument within the subject as the instrument is moved within the subject with a plurality of first tracking devices connected to the instrument;

tracking an ultrasound probe configured to image the subject with a second tracking device and connected to the ultrasound probe positioned outside the subject;

determining a relative position of the instrument and the ultrasound probe based on tracked positions of the plurality of first tracking devices and the second tracking device, respectively; and

displaying a path of the instrument that traversed within the subject superimposed on an image generated by the ultrasound probe.

19. The method ofclaim 18, further comprising:

performing with a tracking system the tracking the instrument and the tracking the ultrasound probe.

20. The method ofclaim 19, wherein the tracking system is an electromagnetic tracking system.

21. The method ofclaim 18, further comprising:

displaying a perspective image generated with the ultrasound probe on a display device from a perspective of the instrument, wherein the position of the instrument for determining the perspective is based on the determined relative position of the instrument and the ultrasound probe.

22. The method ofclaim 18, further comprising:

displaying an image generated with the ultrasound probe on a display device; and

superimposing a position of the instrument on the displayed generated image;

wherein the determined relative position of the instrument and the ultrasound probe is based on a calibration of the tracking of the instrument and the tracking of the ultrasound probe and the superimposed position of the instrument is based on the calibration of the tracking of the instrument.

23. The method ofclaim 22, further comprising:

generating image data with the ultrasound probe, wherein the ultrasound probe is a three dimensional (3D) ultrasound probe, wherein the image data allows dynamic 3D ultrasound imaging modality; and

displaying an instrument perspective image generated with the generated image data on a display device; and

wherein the instrument perspective image allows visualization of the subject over time from a perspective of the instrument due to the determined relative position of the instrument and the ultrasound probe, wherein the instrument perspective image is based on generated images from the dynamic 3D ultrasound imaging modality of the ultrasound probe and on a calibration of the tracking of the instrument and the tracking of the ultrasound probe.

24. The method ofclaim 18, further comprising:

displaying a slice of three-dimensional image data generated with the ultrasound probe relative to the tracked location of the instrument or displaying a view of at least a portion of a total path that the instrument has traversed through the subject.

25. The method ofclaim 18, further comprising:

generating three-dimensional Doppler volume with the ultrasound probe; and

displaying a metric or statistical measurement for flow or motion relative to the instrument.

26. The method ofclaim 25, wherein the generated three-dimensional Doppler volume is a color coded representation of the generated three-dimensional Doppler volume relative to the tracked position of the instrument.

27. The method ofclaim 18, further comprising:

displaying a look ahead view from the instrument, wherein the look ahead view is based on a vessel position and views transverse to a vessel or axial to the vessel.

28. The method ofclaim 18, further comprising:

displaying an image based on image data acquired with the ultrasound probe;

displaying projected trajectories of a forward advance of the instrument to be superimposed on the displayed image.

29. The method ofclaim 18, further comprising performing a procedure with the instrument.

30. The method ofclaim 29, wherein the performing the procedure includes a dual delivery of a therapy.

31. The method ofclaim 18, further comprising:

generating images with an external imaging system operating in a modality different than the ultrasound probe and generating a second image; and

displaying an image generated with the ultrasound probe and the second image.

Images